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Extracorporeal shock wave therapy in the treatment of inferior calcaneal enthesophytosis: outcome by fan-beam dual x ray absorptiometry (DXA)
  1. R Cosentino,
  2. B Frediani,
  3. R De Stefano,
  4. C Acciai,
  5. S Manca,
  6. E Selvi,
  7. E Frati,
  8. R Marcolongo
  1. Section of Rheumatology, University of Siena, Italy
  1. Correspondence to:
    Dr R Cosentino
    Institute of Rheumatology, Policlinico Le Scotte, 53100 Siena, Italy;

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Plantar fasciitis with heel spurs is a common cause of heel pain, and is often not sensitive to conservative treatment, including insole supports, non-steroidal anti-inflammatory drugs, local steroid injection, and physical therapy.1,2 In patients in whom conservative treatment fails, surgical intervention is recommended.3

Recently, extracorporeal shock wave therapy has been introduced for the alleviation of painful heel and other conditions such as tennis elbow, calcifying tendinopathy of the shoulder, and non-union of fractures of the long bones.4–7

The presence and size of the heel spurs do not correlate with the clinical symptoms.4,8

Twenty patients aged between 40 and 70 years were treated. Exclusion criteria were degenerative diseases and/or inflammation of the ankle or foot joints, neurological abnormalities, nerve entrapment syndrome, pregnancy, infectious or neoplastic diseases, ulcerations, and bursitis.

Inclusion criteria were painful heel for a minimum of 12 months with heel spur radiologically examined and unsuccessful conservative treatment during the 6 months before referral to our hospital. No other treatment or drug was used during the 4 weeks before the trials began or during the study period, only the use of insole supports was permitted. An electrohydraulic system was used (Orthima; Direx Medical System Ltd).

Five treatments were given (one every 7 days), each treatment comprising 1200 shocks with a frequency of 120 shocks a minute. As the treatment may be initially painful, the energy density used on starting treatment was 0.03 mJ/mm2, which was gradually increased to 0.4 mJ/mm2.

Variations in the bone mineral content (BMC) of enthesophytosis were evaluated by fan-beam dual x ray absorptiometry (DXA) using a Lunar-Expert version 1.72, at baseline and 1 month after the end of treatment.9 This method allows rapid scanning of particular skeletal regions, and provides a radiographic-like image.10 Scans of 1 mA were applied to the heel, the foot was placed in complete extra-rotation, using a plastic support specific for a DXA evaluation of small bone structures. A region of interest was created in each patient, with a side at the base of the enthesophytosis, to include the enthesophytosis and to exclude the os calcis cortex; this region of interest remained unchanged for later controls (fig 1). The short term precision of the method was 0.5% (coefficient of variation) in vivo, as calculated in 10 patients scanned four times.

Figure 1

 Fan-beam DXA of the heel.

Pain levels were evaluated (before treatment, at the end of treatment, and 3 and 6 months later) by visual analogue scale (VAS) ranging from 0 = no pain to 10 = maximum pain, at rest, after walking on awakening, and after normal daily activity. A significant decrease of VAS (p<0.0001, Wilcoxon test) was seen (table 1).

Table 1

 Pain levels

DXA analysis of enthesophytosis showed a significant decrease in BMC (p<0.001, paired Student’s t test) from an average of 0.162 g to a mean of 0.111 g.

In conclusion, we found that extracorporeal shock wave therapy significantly improved the painful symptoms; in our study this reduction in pain was accompanied by a significant decrease of the BMC of the heel spur.


We thank Dr Silvia Manganelli for language assistance.